Provider Demographics
NPI:1073645461
Name:PINES DIAGNOSTIC TESTING GROUP INC
Entity Type:Organization
Organization Name:PINES DIAGNOSTIC TESTING GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CIANCIULLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-275-6069
Mailing Address - Street 1:11011 SHERIDAN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33026-1505
Mailing Address - Country:US
Mailing Address - Phone:954-443-8010
Mailing Address - Fax:305-412-8265
Practice Address - Street 1:11011 SHERIDAN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33026-1505
Practice Address - Country:US
Practice Address - Phone:954-443-8010
Practice Address - Fax:305-412-8265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U1774Medicare ID - Type Unspecified